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Microsoft word - guidance on prescribing situations not covered by the nhs.doc
Guidance on Prescribing in Situations not covered
by the NHS
All healthcare professionals must exercise their own professional judgement when using
guidelines. However any decision to vary from the guideline should be documented in the
patient records to include the reason for variance and the subsequent action taken.
2010 or sooner in response to new local/national guidance
Key individuals involved in developing the document
Circulated to the following individuals for comments
Head of Medicines Management & Pharmacy
Key individuals involved in developing the document .2 Circulated to the following individuals for comments .2 1 INTRODUCTION .4
PRESCRIBING FOLLOWING A PRIVATE CONSULTATION.4
PATIENTS TRAVELLING ABROAD FOR 3 MONTHS OR LESS .6
7 PATIENTS LIVING / TRAVELLING ABROAD FOR MORE THAN 3 MONTHS OF
VACCINES FOR OCCUPATIONAL HEALTH PURPOSES.7
PRESCRIBING OF MEDICINES FOR AN UNLICENSED USE .7
10 PRESCRIBING OF UNLICENSED SUBSTANCES NOT IN THE ADVISORY
COMMITTEE ON BORDERLINE SUBSTANCES (ACBS) LIST.8
The purpose of this document is to clarify situations where NHS responsibility for
prescribing is not clear and provide guidance to all prescribers (currently including General
Practitioner, locum doctors, and non-medical prescribers) in order that they can make their
own clinical judgement of situations as they arise. 2 AIMS
The aim of the guidance is to provide advice on the following circumstances:
• Patients living abroad for more than 3 months of the year
• Prescribing of medicines for an unlicensed use.
• Prescribing of unlicensed substances not in the Advisory Committee on Borderline
• Prescribing outside of National Guidance e.g. vaccinations or local guidance e.g.
Equality impact assessment issues must be considered in all the above situations. 3 SCOPE OF THE GUIDANCE
This guidance is appropriate for all prescribers; GPs, Community Practitioner,
Supplementary and Independent non-medical prescribers within Worcestershire.
Prescribers should also refer to:
• The Policy and Procedures for the Prescribing, Requisition, Storage, Administration
and Control of Medicinal Products (The Medicines Policy)
• The Policy and Procedures for Non Medical Prescribing
• The Policy for Managing Inappropriate or Excessive Prescribing
4 PRESCRIBING FOLLOWING A PRIVATE CONSULTATION
In general, patients who choose to be referred privately should expect to pay the full cost of any treatment received in relation to the referral. This includes the cost of any medicines and appliances. This is based on the premise that the doctor who accepts responsibility for a particular aspect of care is also responsible for prescribing. Where the consultant has clinical responsibility (e.g. administers the drug) or the treatment is a specialist one, the consultant is responsible for issuing the prescription.
4.2 Following the initial referral, there may be ongoing situations that become the
responsibility of the GP who has overall responsibility for the care of the patient. When continued medication is required, patients should be assessed in the same way as NHS patients; the GP cannot be made to prescribe the recommended treatment if it is contrary to their normal clinical practice or not in line with local formularies.
If patients insist on a treatment outside the formulary and the GP considers the medication inappropriate clinically, or financially unjustifiable for the PCT, it is possible the private specialist may continue to prescribe privately. Otherwise the patient can be referred back to the private consultant for an alternative therapy.
The practice of supporting private patients using NHS funding is not supported. Individuals remain free to spend their own money as they see fit, but public funds will be devoted to NHS patients, and will not be used to subsidise individuals’ privately funded healthcare. For further information on co-funding or funding of private healthcare please refer to the PCT Commissioning Policy – Requests for funding of private healthcare.
If it is considered there is no clinical need or the patient would not normally receive treatment under the NHS, or there are special NHS arrangements (e.g. interferon for multiple sclerosis, IVF), then the patient should be advised of this and if necessary referred back to the specialist and/or into the NHS scheme. If the recommended treatment is out of licence, particularly complex or not recommended by the Midlands Therapeutics Review and Advisory Committee (MTRAC), then the prescriber can also consider referring treatment back to the specialist.
4.6 When a private referral is made patients may be given the leaflet shown in
Appendix 1, explaining the situation regarding NHS prescriptions following private consultations. Enclosing a copy with any referral letter may also be useful.
Private prescriptions can be justified for the following situations: • Travel vaccines where there is no item of service payment (see section 6.4)
• Private care of patients not
on the practice list for NHS care e.g. private GP
appointments or an occupational health service; issuing an NHS prescription in this case would constitute a breach of the GMS contractual regulations
• Malarial prophylaxis and other travel medicines (see section 6.2 and 6.3)
• Drugs on the SLS list being used outside the recommendations e.g. Viagra®
5 VISITORS FROM OVERSEAS
Patients entitled to NHS treatment in primary care including the provision of any necessary
prescriptions are as follows:
• A person intending to be resident in this country for 6 months or more (registration
• Patients from within the European Economic Area in possession of a European
• Patients who require immediate/necessary treatment (EHIC is not required) i.e.
essential treatment, which cannot be reasonably delayed until the patient returns home.
• Patients holding E112 for specific treatment of a particular condition (and
• Refugees (those whose applications to reside in this country have been approved)
and Asylum Seekers (those who have submitted an application and are awaiting a decision)
Patients should be encouraged to register, permanently or as a Temporary
Resident, with a General Practice to receive NHS care. Where overseas patients receive
NHS prescriptions, prescription charges are applicable under the usual rules. Patients who do not fall within any of these categories may be offered and charged
for private care including the provision of private prescriptions where necessary.
6 PATIENTS TRAVELLING ABROAD FOR 3 MONTHS OR LESS
By law the NHS ceases to have responsibility for medical care of patients
when they leave the UK.
People travelling within Europe are advised to carry a
European Health Insurance Card (EHIC) at all times, this gives entitlement to local
health care arrangements. Patients should be advised to check specific
entitlements prior to travel.
• For patients who will be out of the Country for less than 3 months, it is reasonable
to provide sufficient medicines for an existing condition.
• For patients leaving the UK for more than 3 months, they should be advised to
register with a local doctor for their continuing medical needs. It is reasonable for GP’s to provide sufficient medication to give patients time to do this. It may be worth mentioning to patients that medicines can be purchased without a prescription from pharmacies in some countries.
GP’s are not required by their terms of service to provide prescriptions for the
treatment of a condition that is not present and may arise while the patient is
• For P and GSL items, patients should be advised to purchase items required before
• For Prescription Only Medicines (POM), patients may be offered and charged for a
private prescription e.g. Ciprofloxacin for traveller’s diarrhoea. The GMS contract allows items for travel to be prescribed by GPs for patients on their NHS list. This does not apply to other items e.g. influenza vaccine, except those listed above under 4.7.
Drugs for malaria prophylaxis not prescribable on the NHS (British National
• Patients should be advised to purchase where possible over the counter.
• For prescription only medicines (eg. Doxycycline, Lariam®, Malarone® and
Maloprim®), GPs may charge for and issue a private prescription. The GMS contract allows items for travel to be prescribed by GPs for patients on their NHS list.
Patients, including those on a GP’s NHS list, may be charged privately for
travel vaccines not reimbursable on the NHS, through the Global Sum.
Travel vaccines available through the NHS, for which practices receive
All other travel vaccinations are not available on the NHS and must therefore be offered to patients as a private service. Practices may accept a fee from its registered patients for the provision of travel vaccinations; these include;
LIVING/TRAVELLING ABROAD FOR MORE THAN 3 MONTHS OF THE
The NHS accepts responsibility for supplying ongoing medication for temporary periods
abroad of up to 3 months. If a person is going to be abroad for more than three months
then all that the patient is entitled to at NHS expense is a sufficient supply of his/her
regular medication to get to the destination and find an alternative supply of that
medication. 8 VACCINES FOR OCCUPATIONAL HEALTH PURPOSES
The ‘Immunisation against infectious disease’ (2006) gives clinical recommendations for
the use of vaccines, however it does not identify those which are recommended to be NHS
funded. Where no remuneration is available from the PCT for individual vaccines, NHS
prescribing is strongly discouraged.
A patient sent by an employer to request occupational health immunisations should be
advised that this is not the responsibility of the practice. The employer (not the patient) will
have to make private arrangements with a practice, or occupational health provider to
administer the vaccine(s).
Hepatitis B vaccinations for occupations as listed in the BNF should normally be provided
by the employer via their own occupational health provider or private agreement with the
practice’ 9 PRESCRIBING
MEDICINES FOR AN UNLICENSED USE
Prescribing of medicines that are licensed, but are being used outside of their product
license is not generally recommended. However, it is recognised that some circumstances
may necessitate a prescription.
Points for consideration:
1. Prescribers have a duty in common law to take reasonable care and to act in a way
consistent with the practice of a responsible body of peers of similar professional standing.
2. Legal responsibility for prescribing falls to the practitioner who signs the prescription, or
in primary care, the practitioner whose stamp is detailed on the FP10.
3. In situations following a recommendation by a consultant, the prescriber is unlikely to
be found negligent if they have taken steps to become familiar with the drug; are able to monitor the drug completely; and have access to effective consultant support.
4. When an unlicensed use of a medicine is prescribed, the prescriber is
professionally accountable for his judgement in doing so, and may be called
upon to justify his actions.
10 PRESCRIBING OF UNLICENSED SUBSTANCES NOT IN THE ADVISORY
COMMITTEE ON BORDERLINE SUBSTANCES (ACBS) LIST
Worcestershire PCT advises against
the prescribing, at National Health Service expense,
of preparations such as:
Glucosamine Sulphate 1
Antioxidants for Age-related Macular Degeneration (AMD)2
Gamolenic Acid 3
Progest Cream® 4
St John’s Wort
Cod Liver Oil
And other unlicensed products (preparations generally not listed in the BNF)
The rationale behind this decision is:
• They are unlicensed drugs under the Medicines Act, so there is no approved summary
of product characteristics (SPC) for prescribers to consult. (N.B. prescribers are only indemnified by a drug company if there is an SPC and if the drug is used within licensed indications)
• Some are classed as ‘food substitutes’ but are not covered by ACBS regulations and
do not appear in the current British National Formulary (BNF) or the Drug Tariff.
• The Worcestershire Area Prescribing Committee (APC) has not approved them and
• Although relatively low cost, demand could be very considerable if significant
Practices are advised to review patients receiving prescriptions for these items and
consider an alternative licensed preparation if appropriate. Initiation for new patients is
not recommended. It is important that there is equity across the PCT.
continuing to prescribe these products will be asked to justify their use in accordance with
the NHS (General Medical Services) Regulations.
1. Glucosamine Sulphate
Refer to Worcestershire Area Prescribing Committee Guidelines (APC), produced November 2007, on recommendations for Prescription of Glucosamine for osteoarthritis. The guidelines state:
• The evidence of benefit for glucosamine in osteoarthritis is inconsistent and
• Consequently, the prescribing of glucosamine on the NHS is not recommended
within Worcestershire and prescribers are advised not to prescribe glucosamine on FP10.
• Whilst evidence of benefit is minimal, there is little evidence of harm and if patients
wish to purchase the product directly, they should be advised to purchase an over-the-counter containing glucosamine sulphate.
NICE clinical guideline 59 – Osteoarthritis does not support the prescribing of glucoasmine.
Refer to Worcestershire APC Guidelines, produced December 2007, for the prescription of antioxidants in AMD. The guidelines state:
• The prescribing of antioxidants for AMD is not licensed nor supported by robust trial
evidence. Prescribers are recommended not to prescribe antioxidants on FP10.
Following the withdrawal of Efamast® and Epogam® there remain some unlicensed preparations available through Health Food shops. Given the lack of evidence to support continued use of the licensed products and the blacklisting of Evening Primrose Oil capsules and other gamolenic acid products (e.g. Gamophase®), it has been decided not to support the use of related products as medicines.
This unlicensed product is a topical cream derived from wild yams containing natural progesterone. It is promoted for use in women with menopausal or premenstrual symptoms; claims with regard to osteoporosis have also been made. It has been decided not to support the use of Progest® Cream as there is insufficient evidence.
Despite being unlicensed this product is used by Child and Adolescent Mental Health Services. The evidence regarding its use is limited and there is no clear guidance on duration of treatment and how to discontinue, although it appears to be well tolerated. APC have agreed that it should only be prescribed by a specialist, and is not suitable for GP prescribing.
11 PRESCRIBING OUTSIDE OF NATIONAL OR LOCAL GUIDANCE
National and Local guidance will often clarify what GPs should do for identified individuals,
for example whom to immunise against influenza or Human Papilloma Virus (HPV). Whilst
issuing an FP10 for patients who fall outside of these recommendations is not prohibited,
practices should be aware that this would be considered an example of inappropriate
prescribing that would be investigated under the Policy for Managing Inappropriate or
Excessive Prescribing. 12 MONITORING
The Medicines Management Team will use Prescription Pricing Authority (PPA) data to
monitor the prescribing of the more unusual treatments such as those for IVF or interferon.
Practice Based Pharmacists will monitor the use of unlicensed products within their GP
practices using the PPA data available. 13 REFERENCES
Immunisation against infectious disease (2006) Dept. of Health http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Greenbook/DH_4097254
2. British Medication Association Website (www.bma.org.uk) - Information and guidance
Worcestershire Area Prescribing Committee Guidelines http://www.worcestershirehealth.nhs.uk/WorcestershirePCT/Policies_and_Procedures/prescribing.asp
WORCESTERSHIRE PRIMARY CARE TRUST
INFORMATION FOR PATIENTS CONSIDERING
PRIVATE MEDICAL CONSULTATIONS
When you are referred by your GP to a private specialist for a medical consultation you
should be aware of what may happen with any medication needs following the
Sometimes you may only need one prescription and usually your private specialist will
provide a private prescription and you must pay for the medication. Occasionally you may
be advised to contact your GP to obtain an NHS prescription for the medication. If you
need continued treatment you may be given just one private prescription and advised to
return to your GP for NHS prescriptions for the continued treatment.
Whether you need one prescription or continued treatment your GP will assess your
medication needs in the same way as NHS patients are assessed. A prescription will
only be provided if your GP considers there is a clinical need and that an NHS
patient would be treated in the same circumstances.
In order to judge your clinical
need your GP must have received a full clinical report from the private consultant and
therefore you may not be able to have a prescription immediately.
The local doctors have agreed to prescribe from a carefully selected list of medications
and in line with local policies (a formulary). If the recommendation from your private
specialist is for treatment that is not in the formulary then your GP may change the
medication in line with the drugs used for NHS patients locally
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